| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D7140 |
Extraction, erupted tooth or exposed root |
591 |
211 |
$33K |
| D0210 |
Intraoral - complete series of radiographic images |
188 |
177 |
$8K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
178 |
177 |
$4K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
60 |
32 |
$3K |
| D0120 |
Periodic oral evaluation - established patient |
58 |
57 |
$854.00 |
| D0274 |
Bitewings - four radiographic images |
28 |
28 |
$520.00 |
| D0220 |
Intraoral - periapical first radiographic image |
69 |
69 |
$315.00 |
| D0230 |
Intraoral - periapical each additional radiographic image |
65 |
29 |
$300.00 |